Low Back Pain: a New Comprehensive Pathogenetic Model Supporting Methods of Medical Rehabilitation

Abstract

The pathogenesis of chronic low back pain remains elusive. It is still considered a «non-specific» condition, with severity loosely related to anatomical alterations of the lumbar spinal canal (e.g., disc herniation, spinal stenosis). Signs and symptoms may appear contradictory, such as pain aggravated by rest or spinal loading, opposite lumbar postures (flexed or extended) adopted by different patients, and others. Guidelines and reviews oscillate between a restrictive nerve compression model to large sets of epidemiologic factors (from lifestyle to chronic lumbar stress to genetic determinants). A new pathogenetic model is presented here, based on the variable interaction between three possible determinants: compression of nerve endings by disc herniation or arthritic spurs, engorgement of the epidural (Batson) venous plexus, and inflammation triggered by focal thrombophlebitis and fostered by fibrinolytic defects. Hence, the name Compressive-Venous-Inflammatory (CoVIn) is given to the model. Biological and clinical studies provide evidence for each of the three cited determinants. The integrated model explains many «unexplained» characteristics of LBP and provides a rationale for mechanical treatments targeting one or more of the three determinants. Active Lumbar Traction (auto-traction), water exercise, and Williams’ flexor exercises look highly consistent with the model, which can explain their effectiveness.